GUIDANCE ON DEATH CERTIFICATION DURING THE COVID-19 PANDEMIC

This guidance is intended to complement standard guidance for completion of a
Medical Certificate of Cause of Death (MCCD) by assisting medical
practitioners during the COVID-19 pandemic with:
– their clinical responsibilities for appropriate certification of death;
– the adoption of uniform terminology of the disease and the virus; and
– support the reduction in time to provide the MCCD.

COVID-19 as a Notifiable Disease

The Department made Coronavirus Disease (COVID-19) a notifiable disease
through The Public Health Notifiable Diseases Order (Northern Ireland) 2020.
Whilst a notifiable disease, COVID-19 deaths do not need to be reported to the
Coroner unless the death meets the requirements of Section 7 of the Coroners
Act (Northern Ireland) 1959.

Who can complete the MCCD?

Doctors certifying deaths do so as a statutory duty under the Births and Deaths Registration (Northern Ireland) Order 1976 Section 25(2). and do so to the best
of their knowledge and belief.

The Coronavirus Act 2020 made the following provision for the completion of a
MCCD:

  • If the medical practitioner (Dr A) has treated the deceased within the last 28 days and the death is as a result of a natural illness, then the MCCD can be completed as usual.
  •  If Dr A has treated the deceased within the last 28 days but is unable to complete the MCCD or it is impracticable for Dr A to do so (i.e. through unavailability, illness or pressure from other duties etc.), another practitioner (Dr B) from the same hospital or GP practice, can sign the MCCD, provided the deceased died as a result of a natural illness and Dr B can state, to the best of their knowledge and belief, the cause of death.
  • In the event that neither Dr A nor Dr B can complete the MCCD, any medical practitioner (Dr C) can complete the MCCD, as long as the death was as a result of a natural illness and they can state the cause of the death to the best of their knowledge and belief. Dr C does not have to have treated the deceased within the last 28 days.

     

Completing the MCCD

The World Health Organisation has stated that for the purposes of the
International Classification of Diseases (ICD), the official name of the disease is
Coronavirus disease (COVID-19). As there are many types of coronaviruses, it
is recommended not to use “coronavirus” in place of COVID-19. This helps to
reduce uncertainty for the classification or coding and to correctly monitor these
deaths.

Medical Practitioners complete MCCDs to the best of their knowledge and
belief. Where there has been a laboratory confirmed positive COVID-19 test the
preferred terminology to be recorded on the MCCD is:
– COVID-19 (confirmed)

In the absence of a confirmed COVID-19 diagnosis, the certifying doctor should
consider any available evidence and information and apply their clinical
judgement as to whether the disease caused, is assumed to have caused, or
contributed to the death. If so, it is acceptable to use the following terminology:
– COVID-19; or
– Probable/Suspected COVID-19

These terms are acceptable as the direct or underlying cause of death and in such circumstances they should be included in Part I of the MCCD. If COVID-19 had been a significant condition contributing to the death but not directly causing it, then it should be included in Part II in the normal manner.

There is increasing evidence that people with existing chronic health conditions or compromised immune systems are at a higher risk of death due to COVID-19. Chronic conditions e.g. such as coronary artery disease, chronic obstructive pulmonary disease (COPD) and diabetes or disabilities may be significant contributors to a death from COVID-19 and if so, they should be reported in Part II of the MCCD.

If the medical practitioner is not able to satisfy themselves on the balance of probabilities of the likely cause of death, then the appropriate action would be to discuss the case with the Coroner.

MCCDs should be completed immediately or as soon as possible after death. It is important for Funeral Directors to have knowledge of the cause of death, particularly when COVID-19 is involved, when they are removing or preparing the body.

Issuing of the MCCD

MCCDs should continue to be completed using either the NIECR for hospital deaths or GRO Form 12 (MCCD booklet) for community deaths.

Once completed, all MCCDs MUST be scanned and emailed immediately to the GRO using: GRO-pandemic@finance-ni.gov.uk

This is vital as registration of the death must be completed before the burial or cremation can take place. Any delay in sending the MCCD to the GRO could add additional stress to the family at such a difficult time.

The email should contain the contact details for the next of kin and, if known the name of the Funeral Director appointed by the family. This will allow for the certificate to be issued directly to the Funeral Director to enable disposal of the body to proceed.

If the family are in attendance and request a copy of the MCCD this should be provided. However, a copy of the MCCD MUST still be scanned and emailed directly to the GRO as directed. Hard copies of any certificates not issued to the next of kin can be retained and sent to the GRO at a later date.

The following documents explain the process to be followed – ‘Walk-through guide for GPs completing a MCCD by using CCG’ along with advice on ‘Emailing the CCG MCCD to the
GRO’.

 

Still Birth Certificates

The process for the completion of a stillbirth certificate remains the same. However, the completed certificate MUST now be scanned and emailed directly to the GRO

using:

GRO-pandemic@finance-ni.gov.uk

The email should contain the contact details for the next of kin (usually the mother) and, if known, the name of the Funeral Director appointed by the family.

If a copy of the Stillbirth certificate is request by the parent(s), this should be provided, however, a copy of the Stillbirth Certificate MUST still be scanned and emailed directly to the GRO as directed. Hard copies of any certificates not issued can be retained and sent to the GRO at a later date.

 

Cremation Process

Where cremation is the preferred means of disposal the terms under which the statutory cremation forms are completed has been modified. The Coronavirus Act states that to complete Form B, the registered medical practitioner does not have to have treated the deceased within the last 28 days, but must be able to certify the cause of death.

This has effect that all references to attending/treating the deceased within the last 28 days prior to death are omitted from Form B. Following completion of Form B, on most occasions it should be sent by the Funeral Director directly to the Medical Referee for appropriate action.

There is no longer a requirement for Cremation Confirmatory Form C to be completed before a cremation can take place.

Referral to the Coroner

During the Pandemic, there is no requirement under Section 7 of the Coroners Act (NI) 1959, for deaths to be reported to the Coroner when the death is as a result of a natural illness (including Covid-19). In a change to usual practice under the Coronavirus Bill, an MCCD can be issued if the deceased had not been treated within the last 28 days, and a medical practitioner can state to their best knowledge and belief, the cause of death.

This allows deaths that would ordinarily have been referred to the Coroner for certification using the Form 14 (Pro-forma) process to be certified using a MCCD.

If the death is not thought to be of natural causes and is in any way suspicious or unexpected the death should still be reported to the Coroner as per Section 7, for their appropriate action.

 

Completing the MCCD via CCG

There is now the facility to complete Medical Certificates of Cause of Death (MCCD) through CCG –Instead of completing a paper MCCD from the printed MCCD book this works like a GP doing a referral to any Hospital OPD in CCG using the Regional Services tab instead of a Trust.

 Ensure that a copy of the Medical Certificate of Cause of Death (MCCD) is e-mailed to GRO-pandemic@finance-ni.gov.uk . This is a necessary step as the Registrar’s offices are currently closed so handwritten MCCDs can’t be given to Next of Kin as would be usual practice for onward conveyance and registration is clearly still required for burial and cremation arrangements.

 If you have knowledge of next-of-kin and funeral director this is useful for the e-mail to GRO

 The only data entry points are freetexting 1a,1b, II for cause of death, whether seen after death & a mandatory prompt for a GMC

Letter - GUIDANCE ON DEATH CERTIFICATION DURING THE COVID-19 PANDEMIC- 23/4/2020 - HSS(MD) 28/2020

Guidance on Death Certification during the COVID-19 Pandemic – HSS MD 28 2020

GUIDANCE ON DEATH CERTIFICATION DURING THE COVID-19 PANDEMIC
This communication is to provide additional guidance to all medical practitioners in the completion of a Medical Certificate of Cause of Death (MCCD) during the COVID-19 pandemic

(Please see guidance below)

KEY POINTS

  • COVID-19 is an acceptable direct or underlying cause of death for the purposes of
    completing the MCCD.
  • COVID-19 is not a reason on its own to refer a death to the Coroner.
  • That COVID-19 is a notifiable disease under The Public Health Notifiable Diseases
    Order (Northern Ireland) 2020 does not mean referral to the Coroner is required.
  • All MCCDs must be completed and emailed immediately to the GRO using:
    GRO-pandemic@finance-ni.gov.uk
letter -Coronavirus Act 2020 - Michael McBride - 27/3/2020
The Coronavirus Act 2020 received Royal Assent on Wednesday 25 March 2020 and contains clauses which impact on the death certification process, the issuing of both MCCDs and Stillbirth Certificates and referrals to the Coroner.

The Act makes provision to change who is permitted to complete a MCCD:

  • If the original treating doctor cannot certify the death, then a colleague from the same hospital or GP Practice can certify the death;
  • If the deceased has not been treated within 28 days and dies of a natural illness, any medical practitioner who can state, to the best of their knowledge and belief, the cause of death, is permitted to sign the
    MCCD.There are also changes to the way in which deaths will now be registered. Registration Offices will no longer be open to the public with all registrations being completed remotely.Under these emergency provisions there will no longer be a requirement for medical practitioners or midwives to give the MCCD or Stillbirth Certificate to the informant to take to the General Register Office (GRO).

    Instead the medical practitioner or midwife must send a copy of the MCCD or Stillbirth Certificate to the GRO by electronic means. This will mean that the completed MCCD or Stillbirth Certificate will need to be scanned and sent directly to a specific GRO mailbox.

    These provisions remove the face-to-face contact between the practitioner and the informant and then the informants and registrars. When providing the certificates to the GRO, the contact information on the next of kin should be provided by the clinician/midwife and, where known, the details of the Funeral Director appointed by the family. This will allow the Registrar to contact the next of kin to obtain the required registration information and for the issue of the certificate to the Funeral Director to allow disposal of the body to take place.

    With the removal of the requirement for the certifying doctor to have treated the deceased within 28 days, this will also impact on referrals to the Coroner. This will allow for those deaths, that would ordinarily have been referred to the Coroner for certification using the Form 14 (Pro-forma) process, to be certified using a MCCD.

    These provisions also see modifications to the Cremation Form B completed by the certifying doctor and removes the requirement for the completion of the Cremation Confirmatory Certificate, Form C.